Inspection Reports for
Viva Memory Care at Dresher
1424 Dreshertown Rd, Dresher, PA 19025, PA, 19025
Back to Facility Profile25 Reports
Inspection Report — Jun 11, 2026
Complaint Investigation
Date: Jun 11, 2026
Visit Reason
The inspection was an unannounced partial inspection triggered by a complaint and incident review at the facility.
Complaint Details
The inspection was complaint-related and incident-based. A resident alleged rudeness by a male staff member during care. The investigation was inconclusive due to lack of specific details. No other substantiation status was provided.
Findings
The inspection identified deficiencies related to resident treatment, hygiene practices with towels and washcloths, and incomplete medical evaluations. The facility submitted a plan of correction which was accepted and implemented.
Citations (4)
42c. A resident reported a male care staff was rude during assistance with ADLs and brief changes, contrary to the resident's support plan requiring assistance every two hours. The investigation was inconclusive due to lack of specific details, but care assignment was changed to female-only for the resident.
102f. Used, unlabeled washcloths were found unattended in shared bathrooms designated for residents, violating the requirement for individual towels, washcloths, and soap for each resident. The facility removed shared washcloths and implemented caregiver training and audits.
141a. A resident's medical evaluation form did not include a determination that the resident's needs could be safely met at the Personal Care Home. The form was completed and placed in the resident's chart after the deficiency was identified.
141b1. A resident's annual medical evaluation was missing critical medical information including diagnosis, emergency medical information, allergy and immunization history, medication details, and mobility assessment. The form was completed and placed in the resident's chart.
Report Facts
Residents Served: 50
Current Residents: 11
Staffing Hours - Total Daily Staff: 100
Staffing Hours - Waking Staff: 75
Residents Age 60 or Older: 48
Residents with Mobility Need: 50
Inspection Report — Apr 14, 2026
Monitoring
Date: Apr 14, 2026
Visit Reason
The visit was a partial, unannounced monitoring inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 04/14/2026.
Findings
No regulatory citations or deficiencies were identified during this inspection. The facility was found to be in compliance with licensing requirements.
Report Facts
Resident Support Staff: 0
Total Daily Staff: 82
Waking Staff: 62
Residents Served: 41
Current Residents: 12
Residents Age 60 or Older: 39
Residents with Mobility Need: 41
Inspection Report — Jan 5, 2026
Renewal
Date: Jan 5, 2026
Visit Reason
The inspection was conducted as a renewal inspection combined with complaint and incident investigations to assess compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes.
Findings
The facility was found to be in substantial compliance with regulations but had multiple deficiencies related to incident reporting, staff training, resident care, sanitary conditions, medication management, and documentation. A provisional license was issued with required corrections and follow-up inspections.
Citations (28)
2600.16c The home failed to report a resident's hospital admission for sepsis and respiratory failure to the Department within 24 hours.
2600.18 The home did not post the required influenza information poster year-round as mandated by the Influenza Awareness Act.
2600.23a The resident's assessment indicated need for assistance with ADLs, but staff failed to provide or document required care from 6:00 am to 2:00 pm.
2600.25b The resident-home contract was not signed by the resident or administrator as required.
2600.42b A resident experienced an unwitnessed fall with bruising and was hospitalized with sepsis; documentation of care and supervision was inadequate.
2600.65a Staff person did not receive fire safety and emergency preparedness orientation on the first day of work.
2600.65b Staff person did not complete required orientation training on resident rights, emergency medical plan, abuse reporting, and incident reporting within 40 hours.
2600.65e Direct care staff received insufficient annual training hours in 2025, with some receiving zero hours.
2600.65f Staff did not receive required training on medication administration, dementia care, infection control, and other topics during 2025.
2600.65g Staff did not receive training on emergency preparedness, resident rights, Older Adult Protective Services Act, falls prevention, and new population groups in 2025.
2600.85a Sanitary conditions were not maintained; dried blood was found on resident pillow and linens, and unlabeled bar soap was stored improperly.
2600.95 The shared bathroom lacked a toilet paper holder.
2600.101j Resident's bed pillow lacked a pillowcase.
2600.101j Resident did not have an operable bedside lamp within reach.
2600.132c Fire drill records did not include the number of residents present during drills.
2600.132e Fire drills during sleeping hours were not conducted within required 6-month intervals.
2600.162c Weekly menus were not posted one week in advance as required.
2600.171b The first aid kit in the community van lacked a breathing shield.
2600.183d Discontinued medication was found in the medication cart.
2600.183e A loose pill was found in the medication cart.
2600.190a Staff person administered medications without completing Department-approved medication administration course and lacked required documentation.
2600.225c Resident's assessment was not updated annually as required.
2600.227g Resident participated in support plan development but did not sign the support plan.
2600.231e No documentation that resident and designated person did not object to admission to secured dementia care unit.
2600.234a Resident's initial support plan for secured dementia care unit was not completed within 72 hours of admission.
2600.236 Direct care staff in secured dementia care unit had zero hours of required dementia care training in 2025.
2600.251b Fire drill record entries were illegible and overwritten.
2600.252 Resident records lacked photographs no more than 2 years old.
Report Facts
Residents served: 45
Current residents in hospice: 12
Staff total daily: 90
Waking staff: 68
Residents served: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keyva Washington | Medication Administration Trainer | Supervised medication administration training for staff person I |
Inspection Report — Mar 12, 2025
Complaint Investigation
Date: Mar 12, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit triggered by a complaint and incident review at the facility.
Complaint Details
The inspection was complaint-related and included substantiation of violations related to telephone access, restraint use, medication storage and administration, medication record keeping, medication administration compliance, and medical evaluation documentation.
Findings
The inspection identified multiple deficiencies including lack of private telephone access for residents, improper use of restraints, failure to follow medication storage and administration procedures, incomplete medication records, missed medication doses, and issues with medical evaluations for admission to the secured dementia care unit. Plans of correction were accepted and implemented by the facility.
Citations (6)
Residents did not have access to a telephone to make calls in privacy; staff unaware of cell phone available for private calls.
A resident was physically restrained during a combative incident, contrary to policy that residents shall be free from restraints.
Staff failed to follow safe storage and destruction procedures for controlled substances; medication wastage was not properly witnessed.
Medication administration records did not correctly indicate the name and initials of staff administering medication; documentation errors noted.
Resident did not receive prescribed medication dose at 7 PM as ordered by prescriber.
Resident admitted to secured dementia care unit with medical evaluation completed outside the required 60-day timeframe and included virtual visits not accepted by the facility.
Report Facts
Residents Served: 35
Staff Total Daily: 70
Waking Staff: 53
Current Residents in Hospice: 1
Residents Age 60 or Older: 34
Residents with Mental Illness: 1
Residents with Mobility Need: 35
Inspection Report — Feb 27, 2025
Renewal
Date: Feb 27, 2025
Visit Reason
The inspection was a renewal, provisional licensing inspection conducted on February 27, 2025, to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance overall, with a submitted plan of correction fully implemented. Several deficiencies were identified related to sanitary conditions, trash management, surface cleanliness, emergency telephone numbers, food storage, lint removal, menu posting, medication management, and resident assessments, all with corrective actions accepted and implemented.
Citations (11)
Strong urine smell in various parts of the home including hallways and a resident room.
Trash items found on the ground near the dumpster outside the home.
Oblong yellow stain on carpet outside a resident room due to bleach and chemical discoloration.
No emergency telephone numbers posted by the rotary telephone used by a resident, except an obsolete ambulance number.
Unsealed tub of rainbow sherbet in the freezer with partially raised lid.
Thick accumulation of lint in the lint trap of a dryer used for residents' laundry.
Weekly menus posted without indication of the current week in the cycle.
Discontinued medication (1000-mg APAP tablets) found in the medication cart.
Loose blue and white ovular pill capsule found on the side of a medication cart in the nursing station.
Prescribed medications for residents #2 and #3 were not administered as ordered on 2/20/25 at 8:00 pm.
Initial assessment was not completed for resident #4 within 15 days of admission.
Report Facts
Residents Served: 32
Current Residents in Hospice: 3
Total Daily Staff: 64
Waking Staff: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Juliet Marsala | Deputy Secretary | Signed the licensing letter and certificate of compliance. |
Inspection Report — Dec 30, 2024
Monitoring
Date: Dec 30, 2024
Visit Reason
The visit was a partial, unannounced inspection conducted for provisional monitoring purposes to review the facility's compliance and plan of correction implementation.
Findings
The inspection found multiple deficiencies including unlocked medications for a deceased resident, unsecured poisonous materials accessible to residents, lack of operable bedside lighting for a resident, and failure to maintain record confidentiality and medication storage procedures. The facility submitted and implemented a plan of correction with ongoing audits and staff re-education.
Citations (4)
At least five different medications for a recently deceased resident were unlocked, unattended, and accessible behind the concierge desk.
A container of Dove Original Clean Antiperspirant/Deodorant Stick was unlocked, unattended, and accessible to residents, despite not all residents being assessed capable of safely using poisons.
A resident did not have access to a source of light that can be turned on/off at bedside.
A green medication delivery bin containing at least five different medications was found behind the concierge desk unlocked and unattended.
Report Facts
Residents Served: 31
Current Residents in Hospice: 3
Residents Age 60 or Older: 28
Residents with Mobility Need: 29
Total Daily Staff: 60
Waking Staff: 45
Inspection Report — Dec 30, 2024
Follow-Up
Date: Dec 30, 2024
Visit Reason
The visit was a provisional monitoring follow-up inspection to verify the full implementation of a previously submitted plan of correction for the facility.
Findings
The inspection found multiple deficiencies related to medication security, record confidentiality, poisonous materials storage, and resident bedroom lighting. The facility implemented corrective actions including securing medications, re-educating staff, and auditing compliance to ensure ongoing adherence to regulations.
Citations (4)
Record confidentiality was violated when at least five different medications for a recently deceased resident were found unlocked and unattended in a bin behind the concierge desk.
Poisonous materials were found unlocked and accessible to residents in a room where not all residents were assessed capable of safely using or avoiding poisons.
A resident did not have access to an operable lamp or other source of lighting that can be turned on/off at bedside.
A green medication delivery bin containing at least five different medications was found unlocked and unattended behind the concierge desk.
Report Facts
Residents Served: 31
Current Residents in Hospice: 3
Residents Age 60 or Older: 28
Residents with Mobility Need: 29
Inspection Report — Sep 30, 2024
Original Licensing
Date: Sep 30, 2024
Visit Reason
The inspection was conducted as a new licensing inspection for the newly licensed facility Viva Memory Care at Dresher.
Findings
The facility was found to be in substantial compliance with applicable regulations but had several citations related to safety and sanitary conditions that required correction. The inspection included findings on locking poisonous materials, sanitary conditions, bedside lighting, evacuation times, and fire drill scheduling.
Citations (5)
2600.82c Poisonous materials were found unlocked and accessible to residents who were not assessed as capable of safely using or avoiding them.
2600.85a A large dried spill of an unknown brown liquid was found in the upper cabinets of the activities room.
2600.101j7 Resident 1 did not have access to a source of light that can be turned on or off at bedside.
2600.132d The home exceeded the maximum safe evacuation time of 12 minutes during multiple fire drills conducted between June and September 2024.
2600.132g Fire drills were routinely held at the same times and days, not meeting the requirement to hold drills on different days and times.
Report Facts
Residents Served: 33
Total Daily Staff: 66
Waking Staff: 50
Current Residents in Hospice: 2
Fire Drill Times Exceeding Limit: 4
Inspection Report — Mar 18, 2024
Renewal
Date: Mar 18, 2024
Visit Reason
The inspection was a renewal licensing inspection conducted by the Pennsylvania Department of Human Services to assess compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes.
Findings
The facility was found to have multiple violations related to reportable incident documentation, food safety, medication management, staff training, fire safety, and resident records. A second provisional license was issued with required plans of correction and follow-up inspections scheduled.
Citations (26)
2600.16f The home did not retain copies of reportable incidents between November 2023 and January 2024.
2600.18 The home lacked a current ServSafe food manager certification; the cook's certificate expired and no certified staff was present.
2600.51 The home did not have criminal background checks (ePatch) for certain staff members.
2600.63a The home did not have sufficient staff trained in first aid and CPR; on some days no qualified staff was present.
2600.65i The home lacked access to the annual training record for direct care staff member E.
2600.82c Poisonous materials were not kept locked and accessible poisons were found in the salon.
2600.85d Trash receptacles in kitchens and bathrooms were uncovered, allowing penetration by insects and rodents.
2600.103d Food was stored on the floor in the walk-in freezer, violating storage requirements.
2600.103e Leftover food items were unlabeled and undated in refrigerators and freezers.
2600.103g Food items were stored in unsealed or open containers in the freezer and dry goods shelves.
2600.107c The home did not maintain a 3-day supply of emergency food; some emergency food was expired or opened.
2600.132a The home failed to document unannounced fire drills for October 2023, December 2023, and January 2024.
2600.132b The last fire safety inspection and drill by a fire safety expert was conducted on 05/18/2022, overdue for annual inspection.
2600.132c Fire drill records lacked required details including exit routes and times for drills conducted on 02/05/2024 and 11/13/2023.
2600.141a Medical evaluation for resident #1 lacked medication list and cognitive functioning documentation.
2600.183e A blister pack for resident #2 was torn at the back in slot 1.
2600.185a PRN medications for residents #3 and #4 were not available in the home when needed.
2600.186c Resident #3's medication record was not updated after changes in medication orders were received.
2600.187a Resident #2's medication administration record did not indicate diagnoses or purpose of medications.
2600.187b Resident #2's medication was marked as administered when it was not available; documentation errors noted.
2600.187d Resident #2 was not administered prescribed medications due to unavailability on multiple dates.
2600.190c Medication administration training record for staff E lacked trainer name and completion documentation.
2600.225c Resident #2's most recent additional assessment was not completed timely.
2600.227h Support plans for residents #1 and #5 lacked notation of refusal or inability to sign.
2600.234d Resident #2's support plan was not revised as required.
2600.252 Resident #4's record lacked preadmission screening and initial intake assessment documentation.
Report Facts
Residents Served: 36
Staff: 72
Waking Staff: 54
Fine Amount: 170
Fine Amount: 102
Inspection Report — Dec 11, 2023
Follow-Up
Date: Dec 11, 2023
Visit Reason
The inspection was a partial, unannounced visit conducted on 12/11/2023 for complaint and monitoring purposes, including a follow-up on plan of correction submissions.
Complaint Details
The inspection was complaint-related and included monitoring. The plan of correction was submitted and reviewed with follow-up dates noted.
Findings
The facility was found to have multiple deficiencies related to staff qualifications, training, medication storage, and support plan documentation. The submitted plan of correction was determined to be fully implemented as of the follow-up date.
Citations (5)
Direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry.
Direct care staff person provided unsupervised ADL services without completing and passing the Department-approved direct care training course and competency test.
Resident prescription Eucerin topical cream was located in an unlocked drawer in their bathroom.
Resident participated in the development of support plan but the resident/assessor did not sign the support plan.
Resident participated in the development of support plan but the home did not document notation of inability or refusal to sign the support plan.
Report Facts
Residents Served: 36
Total Daily Staff: 72
Waking Staff: 54
Residents Diagnosed with Mental Illness: 7
Residents with Mobility Need: 36
Residents with Physical Disability: 7
Inspection Report — Nov 15, 2023
Follow-Up
Date: Nov 15, 2023
Visit Reason
The inspection visit on 11/15/2023 was a partial, unannounced follow-up to review the submitted plan of correction related to a fine.
Findings
The facility had multiple medication-related deficiencies including discontinued medications remaining in the medication cart, incorrect pharmacy labeling, incomplete medication administration records, missing staff initials on medication administration records, and failure to follow prescriber's orders. The submitted plan of correction was determined to be fully implemented as of the follow-up date.
Citations (5)
Discontinued medication (Trazadone 50 mg) was found in the medication cart after discontinuation date.
Pharmacy label for resident #2's Quetiapine Fumarate 50 mg was inaccurate and blister pack lacked proper direction change sticker.
Resident #1's medication administration record did not include prescribed medications Hyoscyamine 0.125 mg and Ondansetron 4 mg.
Medication administration records lacked staff initials for several residents on multiple dates.
Resident #2 was not administered Tramadol 50 mg as prescribed on multiple dates, and medication was unavailable on some dates.
Report Facts
Residents Served: 33
Total Daily Staff: 66
Waking Staff: 50
Diagnosed with Mental Illness: 7
Have Mobility Need: 33
Have Physical Disability: 7
Inspection Report — Apr 12, 2023
Complaint Investigation
Date: Apr 12, 2023
Visit Reason
Complaint and incident investigation at Woodland Creek Alzheimer's Special Care Center to assess compliance with Personal Care Homes regulations.
Complaint Details
The inspection was complaint-driven with substantiated findings of abuse, neglect, medication errors, and regulatory noncompliance.
Findings
Multiple violations were found including resident abuse, failure to follow physician orders, medication errors, improper storage of poisonous materials, and deficiencies in support plan documentation and accessibility. The facility was issued a provisional license with required plans of correction.
Citations (25)
42b - Abuse: Staff member B physically abused resident 1 by backhanding and pulling them, and the incident was not reported timely.
16c - Written Incident Report: The home failed to report the abuse incident to the department within 24 hours as required.
54a - Direct Care Staff: A direct care staff person lacked a US high school diploma, GED, or active nurse aide registry status.
57c - 2 Hours/Day: Direct care staffing hours were insufficient to meet the minimum required personal care hours for residents with mobility needs.
57d - Waking Hours: Less than 75% of required personal care service hours were provided during waking hours.
162c - Menus Posted: Weekly menus were not posted in a conspicuous and public place in the home.
227g - Support Plan Signatures: Resident support plans were not signed or dated by residents or assessors as required.
42b - Abuse: Neglect in following physician orders for treatment of resident #1 resulted in a scabies outbreak affecting multiple residents.
42y - Health Care Choice: Residents were denied access to their primary care physician on two occasions.
82c - Locking Poisonous Materials: Poisonous creams and disinfectants were unlocked and accessible to residents not assessed as safe to handle them.
185a - Implement Storage Procedures: Medications including Permethrin cream and Albuterol inhaler were not available or misplaced at times.
187b - Date/Time of Medication Admin.: Medication administration records lacked initials of staff administering medications on multiple occasions.
187c - Refusal of Medication: Resident refusals of medication were not reported to the primary care physician as required.
187d - Follow Prescriber's Orders: Several residents did not receive medications or treatments as prescribed, including Permethrin cream and Pantoprazole.
188b - Medication Error Reporting: Medication errors were not immediately reported to residents, designated persons, or prescribers.
190a - Completion Medication Course: A staff person administering medications had an unsigned practicum indicating incomplete competency documentation.
17 - Record Confidentiality: Residents' medication records and narcotics logs were left unlocked and unattended in a public area.
85a - Sanitary Conditions: A strong odor of urine was observed in a resident's room indicating unsanitary conditions.
141b1 - Annual Medical Evaluation: A resident's annual medical evaluation was overdue.
183b - Meds and Syringes Locked: A medication cart containing narcotics and syringes was left unlocked and unattended.
183d - Prescription Current: Discontinued medications were found in medication carts.
224a - Preadmission Screen Form: Resident's preadmission screening did not document need for secured care due to dementia.
227i - Support Plan Accessible: A resident's support plan was inaccessible to direct care staff.
231c - Preadmission Screening: A resident's cognitive preadmission screening was not completed within 72 hours prior to admission to secured dementia care unit.
234d - Support Plan Revision: Support plans were not updated annually or after significant changes in resident condition or behavior.
Report Facts
Residents served: 45
Residents served: 41
Residents served: 32
Fine per resident per day: 5
Calculated fine per day: 160
Total daily staff: 90
Waking staff: 68
Total daily staff: 82
Waking staff: 62
Total daily staff: 98
Waking staff: 74
Inspection Report — Apr 3, 2023
Renewal
Date: Apr 3, 2023
Visit Reason
The inspection was a renewal visit to assess compliance with licensing regulations for Woodland Creek Alzheimer's Special Care Center.
Findings
The inspection identified multiple deficiencies including failure to immediately report suspected abuse, incomplete incident reporting, missing fee schedules in resident contracts, failure to refund residents timely, neglect and abuse of residents, unsecured poisonous materials, uncovered trash receptacles, improper refrigerator/freezer temperatures, incomplete emergency procedures, incomplete medical evaluations, missing menus, improper medication storage, incomplete preadmission screenings and assessments, and incomplete support plans.
Citations (18)
15a - Resident Abuse Report: The home failed to immediately report suspected abuse of a resident on March 9, 2023, violating the Older Adult Protective Services Act.
16c - Written Incident Report: The home did not report several incidents to the department within required timeframes, including abuse complaints and resident injuries.
25c2 - Fee Schedule: Resident-home contracts for multiple residents did not include a fee schedule specifying actual amounts charged for available services.
28d - Resident's Discharge: The home failed to refund balances due to residents within 30 days of their departure.
42b - Abuse: A resident was found with three pairs of incontinence products on, indicating neglect; the responsible staff member was terminated.
82c - Locking Poisonous Materials: Poisonous materials including toothpaste and deodorants were unlocked and accessible to residents not assessed as safe to handle them.
85d - Trash Receptacles: An uncovered trash can was found in the kitchen, violating sanitation requirements.
103f - Refrigerator/Freezer Temps: The main kitchen freezer temperature was above required levels, reaching 20°F and 16°F on April 4, 2023.
107b - Emergency Procedures: The home's emergency procedures did not include contact information for each resident’s designated person.
141a - Medical Evaluation Information: The medical evaluation of a resident did not include special health or dietary needs.
162c - Menus Posted: Weekly menus were not posted one week in advance in a conspicuous and public place for two consecutive weeks.
183e - Storing Medications: Prescription medications for several residents were stored in blister packs with ripped foil backs.
224c - Preadmission Screening: A resident's preadmission screening form was not completed prior to admission.
225a - Assessment 15 Days: An initial assessment was not completed within 15 days of admission for a resident.
227d - Support Plan Medical/Dental: Resident support plans did not document how identified dietary needs would be met.
227g - Support Plan Signatures: A resident participated in the development of their support plan but did not sign it.
231c - Preadmission Screening: A resident's written cognitive preadmission screening was not dated.
234a - Admission Support Plan: A resident's initial support plan was completed late, not within 72 hours of admission to the secured dementia care unit.
Report Facts
Residents Served: 47
Current Residents in Hospice: 7
Refund Amount: 892
Refund Amount: 5000
Freezer Temperature: 20
Freezer Temperature: 16
Inspection Report — Jan 12, 2023
Complaint Investigation
Date: Jan 12, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation at Woodland Creek Alzheimer's Special Care Center to review compliance with regulations and assess the submitted plan of correction.
Complaint Details
The inspection was complaint-driven and incident-related, with follow-up on the submitted plan of correction. The plan of correction was initially not accepted for some deficiencies but later accepted and fully implemented.
Findings
Multiple deficiencies were identified including lack of overnight medication administration staff, absence of CPR-certified staff on certain dates, incomplete annual medical evaluations, failure to follow prescriber's orders, and missing incident reports in resident records. Plans of correction were submitted and later determined to be fully implemented.
Citations (5)
No Med Tech or Nurse present overnight to administer PRN medications on multiple dates.
No staff certified in first aid and CPR present overnight on multiple dates.
Resident's annual medical evaluation was not completed timely.
Medication administered outside the effective dates of the prescriber's order.
Resident records missing incident reports dated on various occasions.
Report Facts
Residents Served: 46
Current Residents in Hospice: 4
Dates without Med Tech or Nurse overnight: 10
Dates without CPR certified staff overnight: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Health Services Director (HSD) | Named as responsible for education, audits, and ensuring compliance with medication administration, CPR certification, medical evaluations, and record keeping. | |
| Nursing Staff | Educated on regulations and responsible for following prescriber orders and documentation. | |
| Executive Director (ED) | Responsible for ensuring resident chart audits and report management. |
Inspection Report — Jan 12, 2023
Follow-Up
Date: Jan 12, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by a complaint and incident review to verify the implementation of a previously submitted plan of correction.
Complaint Details
The inspection was complaint-related and included incident reviews. The submitted plan of correction was determined to be fully implemented.
Findings
The facility was found to have fully implemented the submitted plan of correction related to staffing, first aid/CPR training, annual medical evaluations, following prescriber's orders, and resident record content. Continued compliance must be maintained.
Citations (5)
60a Staffing shall meet residents' needs. Resident 1 lacked Med Tech or Nurse coverage overnight on multiple dates to administer PRN medications.
63a At least one staff person per 50 residents must be trained in first aid and CPR. No certified staff were present overnight on multiple dates despite residents being present.
141b1 Residents must have annual medical evaluations. Resident 2's most recent evaluation was incomplete or missing documentation.
187d The home must follow prescriber's orders. Resident 1 received medication outside the prescribed dates due to a data entry error.
252 Resident records must include incident reports. Records for Residents 1, 2, and 3 were missing incident reports dated in 2022 and 2023.
Report Facts
Residents Served: 46
Current Residents in Hospice: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Health Services Director | HSD | Named as providing education and monitoring compliance on multiple deficiencies including medication administration, medical evaluations, and prescriber order adherence |
Inspection Report — Nov 15, 2022
Follow-Up
Date: Nov 15, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to resident aggressive behavior and abuse prevention. The report details incidents involving Resident #1's aggressive behavior towards other residents and staff, and the facility's corrective actions including supervision, notification, and staff reeducation.
Citations (2)
42b - Abuse: Resident #1 became physically aggressive with other residents multiple times, including grabbing and squeezing, requiring staff intervention and hospital evaluation. The facility did not have 1-1 supervision during early morning hours when the resident was aggressive, posing a safety risk.
201 - Safe Management Techniques: The facility failed to use positive interventions to modify or eliminate Resident #1's aggressive behavior from the time the resident got up until 8:00 a.m. when family arrived to provide 1-1 supervision.
Report Facts
Residents Served: 38
Residents Served in Memory Unit: 38
Total Daily Staff: 76
Waking Staff: 57
Inspection Report — Jul 21, 2022
Date: Jul 21, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, due to an incident.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 35
Staffing Hours: 70
Waking Staff: 53
Inspection Report — Jul 21, 2022
Routine
Date: Jul 21, 2022
Visit Reason
The inspection was a partial, unannounced licensing inspection conducted due to an incident.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Residents Served: 35
Residents Served in Secured Dementia Care Unit: 35
Inspection Report — Apr 29, 2022
Renewal
Date: Apr 29, 2022
Visit Reason
The inspection was a renewal visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 04/29/2022 and 05/02/2022 to review compliance of Woodland Creek Alzheimer's Special Care Center.
Findings
The inspection identified multiple deficiencies including missing resident contract signatures, incomplete medical evaluations, medication administration errors, failure to conduct monthly fire drills, unlocked poisonous materials accessible to residents, and incomplete criminal background checks for staff. Plans of correction were accepted for all deficiencies with specified completion dates.
Citations (18)
Resident-home contract for resident #1 was not signed by the resident with no notation of opportunity to sign.
Resident #1's record lacked a signed statement acknowledging receipt of resident rights and complaint procedures.
Criminal background check was not obtained for Staff A at time of hire.
Resident #2's bed was equipped with an uncovered enabler.
An unannounced fire drill was not held during December 2021; fire drill record lacked contact with Regional Director.
No fire drill observed by a fire safety expert in 2021; last observed drill was on 03/16/2022.
Resident #3's medical evaluation indicated 'None' for special health and dietary needs despite secured dementia care requirement.
Resident #4's medical evaluation did not indicate ability to self-administer medications.
Expired medication prescribed for resident #3 was found in the home's medication cart.
Medication prescribed as needed for resident #4 was not available in the home on 05/02/2022.
No documentation regarding disposal of refused medication doses for resident #4 on 04/23/2022 and 04/25/2022.
Medication administration record for resident #1 lacked initials of staff administering medication on 04/08 and 04/29.
Failure to notify prescriber of resident #4's refusal to take scheduled medication on 04/23/2022.
Staff person B had incomplete medication administration observations in 2021 but administered medications in 2022.
Resident #1 was not educated on the right to refuse medication if a medication error is suspected.
Resident #5 was prescribed medication as a chemical restraint for agitation; medication was administered on multiple days.
Resident #3's cognitive prescreening date was written over without proper notation.
Poisonous materials including antibacterial soap and toothpaste were unlocked and accessible in resident rooms without assessment of residents' ability to safely use or avoid poisons.
Report Facts
Residents Served: 37
Total Daily Staff: 74
Waking Staff: 56
Current Hospice Residents: 4
Inspection Report — Apr 20, 2022
Complaint Investigation
Date: Apr 20, 2022
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial review on 04/20/2022 and an off-site review on 04/25/2022 to assess compliance with regulatory requirements.
Complaint Details
The inspection was complaint-driven. The submitted plan of correction was accepted and fully implemented as of the follow-up dates.
Findings
The facility was found to have deficiencies related to support plan needs and record entries legibility. The plan of correction was accepted and fully implemented, with follow-up reviews confirming compliance.
Citations (2)
2600.234.b The support plan for resident #1 did not address ambulating needs. The resident is no longer at the facility, so ambulation needs were not updated.
2600.251.b Resident #1's admission support plan had dates written over without proper notation, preventing proper documentation. Future changes will be dated and initialed by staff.
Report Facts
Residents Served: 38
Total Daily Staff: 76
Waking Staff: 57
Inspection Report — Mar 17, 2022
Follow-Up
Date: Mar 17, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have multiple deficiencies related to abuse, restraints, staff training, menu changes, admission documentation, and support plan compliance. The plan of correction was accepted and documented as implemented with ongoing audits and staff education planned.
Citations (10)
42b - Abuse: Staff member B grabbed resident #1's wrists tightly causing a small tear, constituting abuse and mistreatment.
42p - Restraints: Staff member B restrained resident #1 by holding both wrists to remove a plate, restricting movement.
65b - Rights/Abuse 40 Hours: Staff persons A and B did not complete required training within 40 scheduled work hours.
65c - Ancillary Staff Orientation: Ancillary staff person A did not receive a general orientation to specific job functions prior to working.
162e - Menu Changes: Waffles with pork roll were served instead of French Toast with Sausage Patties without prior resident notice.
202 - Prohibitions: Manual restraint prohibited by regulation was used when staff member B held resident #1's wrists tightly.
231e - No Objection Statement: Resident #2's record lacked documentation of non-objection to admission to the secured dementia care unit.
234a - Admission Support Plan: Resident #1's initial support plan was completed late; resident #2's initial support plan was not completed.
234d - Support Plan Revision: Resident #2's support plan was not revised to reflect new toileting assistance needs despite observed soiling.
234e - Involvement/Participation: Resident #2 and designated person were not involved in development of the support plan.
Report Facts
Residents Served: 33
Hospice Current Residents: 3
Total Daily Staff: 66
Waking Staff: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in abuse and training deficiencies | |
| Staff member B | Named in abuse, restraint, and prohibition deficiencies; terminated as of 3/17/2022 | |
| Staff person A | Named in training deficiency; completed training after audit | |
| Staff person B | Named in training deficiency; terminated | |
| Ancillary staff person A | Named in orientation deficiency; rehired staff member |
Inspection Report — May 5, 2021
Renewal
Date: May 5, 2021
Visit Reason
The inspection was a renewal visit conducted on 05/05/2021 and 05/07/2021 to review compliance with licensing requirements at Woodland Creek Alzheimer's Special Care Center.
Findings
The inspection identified multiple medication administration errors, failure to report incidents timely, unsafe storage of poisonous materials, tripping hazards in the exterior courtyard, and deficiencies in medication documentation and error reporting systems. Plans of correction were accepted and implemented with training completed by 06/30/2021.
Citations (10)
2600.16c - The home failed to report several medication errors to the Department within 24 hours as required. Medication was not available for administration to residents on multiple occasions.
2600.82c - Poisonous materials including body wash, toothpaste, and denture cleaner were unlocked and accessible to residents unable to safely use or avoid poisons.
2600.100a - The exterior courtyard had unsecured storm drain covers presenting a tripping hazard.
2600.185a - The home failed to document glucometer readings on medication administration records and glucometer logs for resident #2.
2600.187b - Medication administration times were not accurately recorded; resident #2's medication was marked administered when it was not available.
2600.187d - The home did not follow prescriber's orders as several medications were not administered due to unavailability.
2600.188b - Medication errors were not immediately reported to residents, designated persons, or prescribers as required.
2600.188c - Documentation of medication errors and prescriber responses were missing from resident records.
2600.188d - The home lacked a system to identify and document medication errors and patterns of errors.
2600.231c - Written cognitive preadmission screenings were not completed within 72 hours prior to admission for residents #2 and #3 to the secured dementia care unit.
Report Facts
Residents Served: 22
Staff: 44
Waking Staff: 33
Current Hospice Residents: 1
Notice — Apr 16, 2021
Date: Apr 16, 2021
Visit Reason
This document serves as a renewal notification and license issuance for Woodland Creek Alzheimer's Special Care Center, confirming the facility's authorized capacity and advising that an annual onsite inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application and outlines the requirement for a future annual inspection.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
Inspection Report — Oct 9, 2020
Monitoring
Date: Oct 9, 2020
Visit Reason
The inspection was a monitoring visit conducted as a partial, unannounced licensing inspection of Woodland Creek Alzheimer's Special Care Center on 10/09/2020.
Findings
No regulatory citations or deficiencies were identified during this inspection.
Report Facts
Residents Served: 19
Current Hospice Residents: 2
Total Daily Staff: 38
Waking Staff: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennie Heinberg | Lead Inspector | Lead inspector for the monitoring visit |
Inspection Report — Apr 22, 2020
Original Licensing
Date: Apr 22, 2020
Visit Reason
The inspection was conducted as a licensing inspection for a new personal care home facility that was not yet serving four or more residents. A re-inspection will be conducted within 3 months to ensure full compliance.
Findings
The facility was found to be in substantial compliance with applicable regulations at the time of inspection. The licensing inspector was unable to complete a full inspection due to the facility being new and having no residents yet.
Report Facts
Residents Served: 0
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